an overview of contraception

1. CONTRACEPTION
Associate Professor Dr Hanifullah Khan

2. Objectives
1. Understand the definition, classification &
terminology
2. Understand the reason for contraception
3. Know the advantages & side-effects
4. Know the proper use of each method
5. To be able to advise on the use

3. Introduction
• Definition – any • Allows to choose
method used to whether & when to
prevent pregnancy have a child
19 May 07 3

4. Reproduction
• Ovulation
• Fertile period
• Fertilisation
19 May 07 4

5. Consequences of unintended
pregnancies - fetus
• Late booking or no booking.
• Fetus more likely to be exposed to harmful sub-
stances (smoking tobacco and drinking alcohol).
• The child is at greater risk of
– weighing < 2.5kg at birth
– of dying in its first year of life
– of being abused
– of not receiving sufficient resources for healthy
development.
Cleland NEJM 2011 5

6. Consequences of unintended
pregnancies - mother
• Late booking or no booking – increased antenatal
risks
• The mother may be at greater risk of physical
abuse
• Her relationship with her partner is at greater risk
of dissolution.
• Both mother and father may suffer economic
hardship and fail to achieve their educational and
career goals.
Cleland 2003
October NEJM 2011 6

7. Reproductive age
• The typical woman - capacity to bear children for
an 39 years of her life
• Different contraceptive methods required for each
life stage
– to accommodate the complex factors accompanying
each stage
• Without contraception - 85% of couples conceive
within 1 year.
Trussell J. Contraception 2010

8. Female Contraception
Reversible Non-Reversible
Hormonal Non-Hormonal Tubal ligation
COC IUD
POP Barriers
POP Spermicides
Injectables
Implants
Emergency
Mirena
7 June 2006 8

9. COMBINED CONTRACEPTION

10. Combined Oral Contraception I
• Large number of users
• Prompt return of ovulation
– 70% in 1st cycle , 98% by 3rd cycle*
• No permanent loss of fertility
• Beneficial effects on future fertility
– ↓ ascending infection & PID (progestogenic effect)
– ↓ risk of EP
– ↑ ferritin levels & Hb
*Rice-Wray E et al. Return of ovulation after discontinuation of oral
contraception. Fertil Steril 1967;18:212-8.

11. Combined Oral Contraception II
• Women who conceive after discontinuation of
COC:
– No ↑ risk of pregnancy loss or EP
– No alteration in sex ratio
• No ↑ miscarriage rate or chromosomal
abnormalities in women who continue COC
during early pregnancy*
• No risk of masculinization
*Huggins GR. Fertility after contraception or abortion.
Fertil Steril 1990;54:559-73.

12. Patch
• Transdermal supply of 750 µg ethinyl estradiol (an
estrogen) and 6000 µg norelgestromin (a progestin)
• Side effects similar to COC
• ? Slightly increased risk of TED

13. PROGESTOGEN ONLY
CONTRACEPTION

14. Progestogen-only Methods
● POP
● Subdermal implants
● Injectables
● Combined injectables
● Emergency contraception
● Mirena

15. Progestogen-only Methods Of Contraception*
Route of Very low dose Low dose High dose
administration
Oral Progestogen-only pill
Subdermal Etonogestrel-releasing
implant (Implanon®)
Levonorgesterel-
releasing implant
(Norplant®)
Intrauterine Levonorgesterel-
releasing intrauterine
system (Mirena®)
Vaginal Vaginal rings (under
development)
Intramuscular Depo-
injection Provera®

16. POP - Effects
• Local effect on cervical mucous & endometrium
– inhibits gamete transport & implantation
• No effect on future fertility
• Does not offer same protection against EP as
COC

17. Subdermal Implants
• Implanon – single rod. Between biceps & triceps
of non-dominant arm.
– 3 year efficacy.
– Inhibits LH surge – ovulation inhibition
– Oestradiol levels unchanged
– The only contraceptive method to have a Pearl Index
of 0.*
– Prompt return of fertility*
• Norplant – older. 6 rods.
*Croxatto HB. The pharmacodynamics and efficacy of Implanon. An
overview of the data. Contraception 1998;58:91S-97S.

18. Implanon

19. Injectables
• DMPA
• Inhibition of ovulation caused by Gn suppression
• Ovulation returns after 4-5 months & median
conception time of 5-7 months*
• No permanent effect on fertility. However, may
take 2 years to return.**
• Delay may be due to slow drug metabolism
(microcrystalline deposits in muscle)***
*Kaunitz AM. Ob/Gyn 1993
** Kaunitz AM. Int J Fertil Womens Med 1998
***Hickey M. Clin Obstet Gynecol 1995

20. Emergency contraception I
• ECP/ "morning-after pills
• a short course
– either a high-dose combination of estrogen & progestin or
– progestin-only
– used within 72 hours of unprotected intercourse to prevent
pregnancy
• taken after SI but before implantation
• more effective the sooner they are initiated after SI.
• estrogen-progestin combinations (commonly known as the
Yuzpe regimen)
– may reduce the risk of pregnancy by 75% and the progestin-
only formulation by 88%

21. EC IUCD
• copper-containing intrauterine device (IUD)
inserted within 120 hours of unprotected
intercourse to prevent pregnancy
• work by the same mechanisms of action as OC -
inhibit ovulation, fertilization, or implantation.
• They will not terminate an existing pregnancy

22. Emergency Contraception III
Levonorgestrel Nordette 4 tablets/dose 2 doses
0.15 mg +ethinyl (light orange
estradiol 30 mcg tablets)
Levonorgestrel Plan B 1 tablet/dose 2 doses
First dose within 72 hours of
0.75 mg unprotected intercourse;
second dose 12 hours
later(no anti-emetic required)

23. NATURAL METHOD
Wednesday 15 23

24. Body changes during menstruation
• Likelihood of pregnancy high if SI just before or
after ovulation
• During the menstrual cycle, a number of changes
occur in a woman's body
– By keeping track of these changes, couples can plan
when to have intercourse and when to avoid
intercourse, depending on whether they are trying to
achieve or avoid pregnancy.
Wednesday 15 24

25. What is natural family planning?
• A way to help decide when SI can or cannot
result in pregnancy
• Learn to recognise the changes in a woman’s
body that shows when she is fertile each month
• Avoid sex at the fertile times, or use condoms or
a diaphragm.
Wednesday 15 25

26. Advantages:
• Acceptable to most faiths and cultures
• No need to take any hormones
• No side effects
• Gives a greater awareness of fertility
• Can be used to plan pregnancy as well as avoid it
Wednesday 15 26

27. Disadvantages
• No protection against STIs
• Takes a long time to learn (3 to 6 months)
• Daily tests and records need to be made
• Illness, stress and travel can affect fertility indicators
• Both partners need to be committed to using the
method
• Unsuitable for:
– Women who can't check their temperature and cervix every
day
– Couples who are even slightly disorganised
– Women with very irregular periods
Wednesday 15 27

28. Methods
• Coitus Interruptus
• Rhythm Method
– Calendar
– BBT
– Cervical Mucous (Ovulation)
– Symptothermal
– Ovulation Predictor Kits
• Abstinence
• Lactational Amenorrhoea Method
Wednesday 15 28

29. Coitus Interruptus
Wednesday 15 29

30. Coitus Interruptus (Withdrawal)
• The penis is withdrawn from the vagina prior to
ejaculation
• When done correctly - failure rate of 6.7% (6.7 out
of every 100 women)
• Advantages - immediately available and it is free
• Disadvantages
– unsure able to withdraw before ejaculating
– preejaculatory fluids may contain viable sperm
Wednesday 15 30

31. Effectiveness
Among typical couples - 19 in 100 will experience an
accidental pregnancy in the first year
o Some men cannot tell when they are going to ejaculate.
o Some men ejaculate very quickly, before they realize it.
o Before ejaculation, almost all penises leak fluid that contains
sperm that can cause pregnancy.
o Some men lack the experience and self-control to pull out in
time.
o Some men are unreliable
o It offers no protection against STD's and infections.
o It's free
Wednesday 15 31

32. Rhythm Method
Wednesday 15 32

33. What is it?
• Also known as "fertility awareness"
• Uses the menstrual cycle to predict the most
fertile time of the month .
• Once the fertile time has been identified - don't
have sex or use a barrier method during that
period.
Wednesday 15 33

34. How does it work?
• Based on the fact that:
– The fertile period lasts about 4 days following
ovulation, when the mature ovum travels through the
fallopian tubes to the uterus and can be fertilized
• Sperm may live in the female reproductive tract for
up to 7 days
• The female egg lives for only a day
• fertilization may occur even days after intercourse
• "safe days" occur 2 days after ovulation and
continue until the next period
Wednesday 15 34

35. How effective is it?
• Choose a fertility awareness method only if:
– There is a cooperative partner
– A regular, steady monthly cycle
– Willing to invest time and effort required to learn about
fertility awareness methods
– accept the fact that protection against pregnancy is not
perfect
• There are no side effects
Wednesday 15 35

36. Several Methods
• Several methods of determining which are the
most fertile days of the cycle:
– Calendar Rhythm Method
– Basal Body Temperature Method
– Ovulation Method
– Symptothermal Method
– Ovulation Predictor Kits
Wednesday 15 36

37. Calendar Rhythm Method
• Requires keeping track of the cycle for 6 to 12 months to
determine the pattern of ovulation -will determine when it is
most "dangerous" to have sexual intercourse.
• Estimate the first and last days of the fertile period
– subtract 18 from the length of the shortest cycle and 11 from the
length of the longest cycle
– if the shortest cycle is 28 days and her longest cycle is 32 days, the
first and last days of the fertile period should be days 10 and 21
– should abstain from SI for 12 days, starting on the 10th day after the
beginning of the menstrual cycle
• The failure rate for this method is 40% (40 out of 100
women).
Wednesday 15 37

38. Shortest cycle (S) minus 18 = Last infertile day of the pre-ovulatory phase
Longest cycle (L) minus 11 = Last fertile day
For example:-
Length of cycles during last six months = 28, 29, 28, 27, 30, 28
(S = 27) S - 18 = Last infertile day 27 - 18 = 9
(L = 30) L - 11 = Last fertile day 30 - 11 = 19
Wednesday 15 38

39. Basal Body Temperature Method
• Keeping track of body temperature
• Body temperature rises two days prior to ovulation.
Wednesday 15 39

40. RECORDING & CHARTING THE BBT
• The temperature should
be taken immediately on
waking before getting
out of bed, drinking tea
or any other activity,
and at about the same
time each morning
Wednesday 15 40

41. THERMOMETERS
• Two types of
thermometer
– Glass / mercury fertility
thermometer
– Digital thermometer
• covers only the range
from 35-39 deg. C
Wednesday 15 41

42. Ovulation (Billing) Method
• Requires feeling and observing the cervical
mucus to determine the time of ovulation.
• Note the production of clear, watery mucus in the
days immediately before ovulation
• To avoid pregnancy, intercourse is avoided for
several days following change in the color and
consistency of cervical mucus.
Wednesday 15 42

43. Changes in the Cervix - in Relation to
Ovulation
Cervical changes take
place over an interval of
around 10 days.
Approximately 6/7
before the shift in
temperature the cervix
will begin to show fertile
characteristics.
Following ovulation, the
cervix returns to its
infertile state within 24-
48 hours
Wednesday 15 43

44. RECOGNISING THE CHANGES IN
CERVICAL MUCUS
• Sensation - at the vulva :the sensation may be a distinct
feeling of dryness, of dampness or moistness, stickiness,
wetness, slipperiness or lubrication.
• Appearance – use toilet tissue to blot or wipe the vulva -
white, creamy, opaque, or transparent (clear).
– Mucus is often noticed on underclothing, where it will have dried
slightly causing some alteration in its characteristics
• Finger Testing - finger-tip applied to the mucus on the tissue
and then pulled gently away to test its capacity to stretch
– It may feel sticky and break easily
– or it may feel smoother and slippery like raw egg white and stretch
between the thumb and first finger, from a little up to several inches
before it breaks. This stretchiness is described as the Spinnbarkeit or
Spinn effect, and shows that the mucus is highly fertile.
Wednesday 15 44

45. Sensation
Finger Test Appearance
at Vulva
Early Mucus
Scanty
Moist
Thick
or
White
Sticky
Sticky
Holds its shape
Transitional Mucus
Increasing Amounts
Wetter Thinner
Cloudy
Slightly Stretchy
Highly Fertile Mucus
Profuse
Thin
Slippery
Transparent
Stretchy
(like raw egg white)
Wednesday 15 45

46. Mucus changes throughout the cycle
Complete cycle showing typical pattern of menstruation, pre-
ovulatory dry days,
mucus days with increasingly fertile characteristics approaching
peak day,
the abrupt change back to less fertile characteristics,
the count of four after peak day and post-ovulatory dry days
Wednesday 15 46

47. Symptothermal Method
• A combination of the calendar and cervical mucus methods
and the woman's basal body temperature (BBT)
• The first day is estimated by subracting 21 from the shortest
menstrual cycle (the calendar method) or noting the first day
of cervical mucus associated with ovulation (the cervical
mucus method), whichever comes first
• BBT is used to predict the end of the fertile period. The
woman takes her temperature every morning and notes when
body temperature rises, indicating that the corpus luteum is
producing progesterone and ovulation has occurred
• She can resume sexual intercourse 3 days after this so-called
thermal shift
Wednesday 15 47

48. Interpretation of the Sympto-Thermal Chart
This sympto-thermal chart shows the correlation between all
indicators of fertility
Wednesday 15 48

49. Fertility Chart
Wednesday 15 49

50. Ovulation Predictor Kits
• used to test urine to identify
hormones that indicate ovulation is
about to occur
• electronic fertility computer tells a
woman which days she is fertile
• Persona: fertile days are indicated
with a red light and infertile days
with a green light
• failure rate as low as 6% among
women who abstain on fertile days
as indicated by the device
Wednesday 15 50

51. Anovulation
• A monophasic chart indicates that there has been no
ovulation in this cycle.
• The temperature remains on one level.
• The bleed, not a true period, is often lighter than
usual.
Wednesday 15 51

52. Faulty technique
• Erratic temperature chart - result of poor technique.
• Implications of disturbances, such as illness, alcohol,
medication, or disturbed sleep patterns and note their occurrence.
• A temperature chart showing erratic and abnormally low
readings usually indicates faulty technique.
Wednesday 15 52

53. Abstinence
Wednesday 15 53

54. Easily stated, not always easily done
• takes commitment from both partners
• Abstinence is the most effective method of
preventing pregnancy and transmitting sexual
disease
• Not having traditional sexual intercourse, so the
penis does not enter the vagina, at all
• Become familiar with the fertility patterns - abstain
from vaginal intercourse on the days pregnancy can
occcur
• Effectiveness - If practiced perfectly, there should
not be any pregnancy.
Wednesday 15 54

55. Pros and Cons
• The Pros
– 1) Anyone can do it, with commitment.
– 2) It's free.
– 3) Encourages the building of a relationship. Trust.
– 4) No supplies
– 5) No infections or STI's
– 6) Endorsed by some religions.
– 7) No hormonal side effects.
• The Cons
– 1) It can be frustrating for some couples.
– 2) If not used properly, infections can be acquired. i.e.
oral sex transmission.
Wednesday 15 55

56. Lactational Amenorrhea
Method
Wednesday 15 56

57. LAM
• Average Failure Rate: 6%
• Most BF women do not ovulate for 4-24 months
postpartum
– whereas non-breastfeeding women can ovulate as early as 1-2
months
• Conditions to be fulfilled
– Fully BF
– No periods
– Recommended up to 6 months - the longer LAM is used, the
more likely it is that ovulation will precede the first menses
• Cervical mucus changes herald the first ovulation
– should start checking daily at six weeks postpartum
• Women with no periods who BF without practicing
LAM - pregnancy rate of 6% over a year. Perfect users
can expect a failure rate of only 0.5%.
Wednesday 15 57

58. What are the advantages of natural family
planning?
• Does not involve the use of medicines, mechanical
devices or chemicals.
– Side effects or risks that may occur with the use of such
medicines or devices will not occur
• Inexpensive
• Require partners to share the responsibility for
planning or avoiding pregnancy
– Typically, couples who use these methods notice an
increase in communication and in cooperation.
Wednesday 15 58

59. INTRAUTERINE DEVICES

60. Introduction
a small device
made of plastic or
copper that is placed
into the uterus as an
effective method of
contraception
60
19 May 07

61. Types
Levonorgestrel- Copper-releasing
releasing device device
19 May 07 61

62. Copper IUDs: Mechanisms of Action
Interfere with
Interfere with reproductive
ability of sperm to process before ova
pass through reach uterine cavity
uterine cavity
Change
Thicken cervical endometrial
mucus lining

63. IUDs: Contraceptive Benefits
• Highly effective
• Effective immediately
• Long-term method (up to 10 years protection with
Copper T 380A)
• Do not interfere with intercourse
• Immediate return to fertility upon removal
• Do not affect breastfeeding
1 Trussell et al 1998.
19 May 07 63

64. IUDs: Contraceptive Benefits continued
• Few side effects
• After followup visit, client needs to return to
clinic only if problems
• No supplies needed by client
• Can be provided by trained nonphysician
• Inexpensive (Copper T 380A)
19 May 07 64

65. IUDs: Noncontraceptive Benefits
• Decrease menstrual cramps (progestin-releasing
only)
• Decrease menstrual bleeding (progestin-
releasing only)
19 May 07 65

66. Who Can Use IUDs
Women of any reproductive age or parity who:
– Want highly-effective, long-term contraception
– Are breastfeeding
– Are postpartum and not breastfeeding
– Are postabortion
– Are at low risk for STDs
– Cannot remember to take a pill every day
– Prefer not to use hormonal methods or should not use
them
– Are in need of emergency contraception
19 May 07 66

67. IUDs: Who Should Not Use
(WHO Class 4)
IUDs should not be used if woman:
– Is pregnant (known or suspected)
– Has unexplained vaginal bleeding until the cause is
determined and any serious problems are treated
– Has current, recent PID
– Has acute purulent (pus-like) discharge
– Has distorted uterine cavity
– Has malignant trophoblast disease
– Has genital tract cancer
– Has an active genital tract infection (e.g., vaginitis,
cervicitis)
Source: WHO 1996.
19 May 07 67

68. IUDs: Common Side Effects
Copper-releasing:
– Heavier menstrual bleeding
– Irregular or heavy vaginal bleeding
– Intermenstrual cramps
– Increased menstrual cramping or pain
– Vaginal discharge
Progestin-releasing:
– Amenorrhea or very light menstrual
bleeding/spotting
19 May 07 68

69. IUDs: Possible Other Problems
• Missing strings
• Slight increased risk of pelvic infection (up to 20
days after insertion)
• Perforation of the uterus (rare)
• Spontaneous expulsion
• Ectopic pregnancy
• Spontaneous abortion
• Partner complains about feeling strings
19 May 07 69

70. IUD Insertion: Withdrawal Method
(2)
Withdraw
inserter tube (1)
Hold
plunger
Source: PATH and Population Council 1989.
19 May 07 70

71. Postpartum insertion
• Delayed (4-6 weeks) or immediate postpartum
insertion
• safe and effective
• Expulsion - more common for immediate than
with interval insertions
19 May 07 71

72. Postabortal insertion
• Safe and practical
• Convenient
• Avoid some discomfort from the procedure
• Expulsion of the device is marginally increased
19 May 07 72

73. Benefits of IUDs
• Long-acting reversible contraceptives
• Require no adherence on the part of the user
– leaving virtually no scope for user error
• More than 99% effective
• Once they’ve been inserted, users need not take
any action to continue using them
– Reduce the number of unintended pregnancies that are
due to user error or contraceptive failure.
• Exceptionally cost-effective.
Trussell J. Contraception 2010

74. CURRENT CONCEPTS IN
CONTRACEPTION

75. Guidelines Regarding the Use of Combination Estrogen-Progestin Contraceptives in Women >=35 Years
of Age, According to Risk Factors
Kaunitz A. N Engl J Med 2008;358:1262-1270

76. Breast feeding
• Previously, progestin-only
• Low dose COC still possible
19 May 07 76

77. Cancer risk
• If used for more than a • Long term –
year – protect against Ca protect against Ca
endometrium ovary
• Those with Ca
• Ca breast? -
breast should not
uncertain
take pill

78. Failure Rates
User Failure Method Failure
19 May 07 78

79. Failure rates
• Implants, IUDs and LNG-IUS - <1%
• Contraceptive pills - 5%
• Male condoms - 14%
• Diaphragm with spermicide - 20%
• Cap with spermicide - 20-40%
• 'Natural' methods - 35%
• Withdrawal - 19%
19 May 07 79

80. 1. Contraception provides an effective means to plan a
family
2. Many methods are available -
suitability has to be decided based on a proper history & examination
3. Pregnancy should be ruled out first
4. You should know the advantages & side effects
5. Contraception also provides non-contraceptive benefits
KEY POINTS

81. Further reading
• Cleland et al. Family Planning as a cost saving
preventive health service. NEJM April 20, 2011.
• Trussell J. Update on the cost effectiveness of
contraceptives in the United States.
Contraception 2010;82:391.